Healthcare Provider Details

I. General information

NPI: 1174785786
Provider Name (Legal Business Name): TAE WOO PARK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TED PARK

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 02/03/2023
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 FORBES AVE FL 9
PITTSBURGH PA
15213-3317
US

IV. Provider business mailing address

3501 FORBES AVE FL 9
PITTSBURGH PA
15213-3317
US

V. Phone/Fax

Practice location:
  • Phone: 412-246-6351
  • Fax:
Mailing address:
  • Phone: 412-246-6351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD14645
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number247886
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number247886
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD436597
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: